Health New Zealand has accepted the findings of a rapid review into an incident where an 11-year-old girl was misidentified as a woman in her 20s, taken to the hospital by police, and given anti-psychotic drugs.
Health NZ released the findings of that review today, which confirmed that “several failings” had contributed to the “distress and trauma” experienced by the girl.
“Once again, and on behalf of Health NZ, I offer our deepest apologies,” Health New Zealand Chief Clinical Officer Dr Richard Sullivan said.
“Our staff endeavour to provide high standards of care and we want to ensure what happened in this particular case cannot happen again.”
Report’s findings
The report found there was an “assumption” that it was a mental health presentation, as police had told hospital staff the girl was found on a bridge displaying mental health symptoms.
“This resulted in the mental health Crisis Assessment and Home Based Treatment team (CAHT team) being called and asked to assess the patient, without Patient A (the girl) being reviewed by the Emergency Department (ED) medical team first.”
The CAHT team had initially considered the possibility of a different diagnosis and declined the direct admission of the girl into an inpatient unit.
An initial assessment of the girl by the CAHT team and an ED registered nurse found the patient “resembled a child that may have a disability”.
The report said this “demonstrated good clinical judgement and the consideration of a differential diagnosis”.
The misidentification by police was accepted by staff as it was common for police to confirm identity.
“Patient A displayed limited verbal ability, and there was no additional information available to staff to verify the Police’s identification. Patient B also had no next of kin in the system to contact.”
The report said no cultural support was provided to the girl, and the ED medical team did not see her – a missed opportunity for a different diagnosis.
The CAHT team accepted the patient and made a treatment plan based on what would have been appropriate for the 20-year-old woman she was thought to be.
“Current Waikato Hospital identification processes are inadequate for this situation,” the report said.
“From this point, there was a failure to consider any other diagnoses to explain the clinical presentation.”
The girl was medicated in the admission area and transferred into the intensive psychiatric care unit.
She declined to take oral medication, which resulted in health staff administering intermuscular medication (IMI). She was restrained while the staff gave her the drug.
“Staff were working on the assumption that they were administering medication to an adult, not a child,” the report said.
“Medication decisions were based on Patient B’s history of rapid escalation of their symptoms.”
It also said the medication was “rarely” administered to children and was not the first-line choice in adults but was given due to a supply shortage. Two doses of the drug were given to the patient, and no mental health reassessment was completed before it was provided.
The girl’s vital signs were not measured before or after sedation. Visuals of the girl post-medication occurred at “frequent intervals”.
The review said the patient’s care was provided “in the timeframes that would normally be expected.”
It also said: “Several staff commented on high workloads and a frequently full unit”.
It found that once the girl was correctly identified, “appropriate actions were taken”, and the support offered to the family following the ordeal continued.
“The event was immediately reported and recorded as an adverse event, and a review process was commenced. This was consistent with Waikato District’s adverse event process.”
Following the review, Health NZ said it would have an action plan to implement a number of recommendations next week.
The recommendations included
- Apologising to the girl and her family; undertake a rapid review of international best practices for the identification of unidentified patients.
- Ensuring all emergency departments undertake medical reviews on unidentified patients.
- Establishing a national restraint group for physical restraint, medication restraint, monitoring after sedation, de-escalation processes and staff training.
- A review of admission criteria and procedures for admission to psychiatric intensive care units.
- A review of workforce resourcing in the Waikato District’s mental health inpatient unit.
- Ensuring cultural support is offered to mental health patients as early as possible.
- Engaging cultural and disability services in the actioning of relevant recommendations.
“We also want to make sure Patient A and their family are given appropriate time and support to understand the findings and recommendations, ask questions, and feedback any concerns into the Waikato Serious Adverse Event report process,” Sullivan said.
Police conduct own review
Police also conducted its own internal district review of the day’s events.
It found that police’s operational response upon hearing a person was on the bridge was “prompt, with appropriate urgency for securing her safety”.
It said the decision to detain the girl was appropriate “given their genuine concerns for Patient A’s safety and wellbeing”.
Police found that the decision to handcuff the girl on arrival at the hospital was “reasonable” to protect her own safety and the safety of staff.
The review said police misidentified the girl despite “genuine attempts to confirm her identity” and “immediately” informed hospital staff of the mistake.
“We acknowledge that the events have been distressing for [the girl] and their family. Waikato Police have met with the family and apologised for the misidentification,” Assistant Commissioner Sandra Venables said.
“What we know at this stage is that the misidentification occurred despite the genuine efforts of our staff to identify the female.
“However, we also know that our processes can be improved to further reduce the risk of an incident like this recurring.”
Venables said the review was still in its information-gathering stage, with the final report to be peer-reviewed before release. The police also self-referred the ordeal to the Independent Police Conduct Authority (IPCA).
‘This event should never have happened’
The Ministry of Health’s Director of Mental Health Dr John Crawshaw said he was considering what further action may be required.
Under the Mental Health Act, the Director of Mental Health has statutory powers to examine the events that took place at Waikato Hospital, including whether an inquiry under Section 95 is required.
“Firstly, I would like to acknowledge the distress this incident has caused to the young person and their whānau. This event should never have happened and it is important that we fully understand what took place,” he said.
“I have now had Health New Zealand’s findings into the event referred to me, I’m looking at the findings and will be considering whether to use my statutory power to instigate a Section 95 Inquiry. In doing so, I will consider how this may sit with any other potential investigations.”
He expected to finish his initial review next week.
A Section 95 inquiry can be instigated under the Mental Health Act by the Director of Mental Health where there are concerns of a systemic nature or there is a major incident that requires an independent statutory investigation.
How the misidentification happened
It was previously reported that the girl, who was reportedly autistic and non-verbal, was mistaken for a 20-year-old mental health patient after she was spotted climbing on the railing at Fairfield Bridge in Hamilton on the morning of March 9.
She was taken to Waikato Hospital by police.
When they arrived, officers decided to put her in handcuffs, as her behaviour had caused “concern for her safety”. She was also given an antipsychotic drug, according to Police Minister Mark Mitchell.
Because the girl did not give any details about her identity and had no documents on her, police nominated a local woman based on a photo comparison, with the help of a mental health service provider, and the description of her age.
Superintendent Scott Gemmell told RNZ that the woman was residing in a community-based mental health facility near the bridge. He said a carer thought the detained girl was the person as well. The nominated woman was not in a mental health facility at the time of the incident.
“Waikato Police staff had sought to confirm the person’s identity with the assistance of a mental health service provider, who was only able to compare a photograph of Patient A (misidentified child) with a photograph held of Patient B (person known to mental health service providers),” Venables said.
“Based on the photo comparison and information available to Police at the time, Police shared their assessment with Waikato Hospital staff, including their rationale for the nominated identity.”
Almost 12 hours after the incident on the bridge, at 6pm, a woman reported that her 11-year-old daughter had gone missing. A member of police staff recognised her as the girl picked up earlier that day, and her family was “immediately” notified about her location. Police took a family member to pick up the 11-year-old.
Gemmell said police were “disappointed and gutted” by what happened.
Prime Minister Christopher Luxon said at the time the incident was “incredibly distressing and incredibly concerning”.
